Methods and apparatus for tools in axially oriented bores through spinal vertebrae

ABSTRACT

One or more tools for use in shaped axially oriented bores extending from an accessed posterior or anterior target point are formed in the cephalad direction through vertebral bodies and intervening discs, if present, in general alignment with a visualized, trans-sacral axial instrumentation/fusion (TASIF) line in a minimally invasive, low trauma, manner. An anterior axial instrumentation/fusion line (AAIFL) or a posterior axial instrumentation/fusion line (PAIFL) that extends from the anterior or posterior target point, respectively, in the cephalad direction following the spinal curvature through one or more vertebral body is visualized by radiographic or fluoroscopic equipment. In one embodiment, curved anterior or posterior TASIF axial bores are formed in axial or parallel or diverging alignment with the visualized AAIFL or PAIFL, respectively, employing bore forming tools that can be manipulated from proximal portions thereof that are located outside the patient&#39;s body to adjust the curvature of the anterior or posterior TASIF axial bores as they are formed in the cephalad direction. Further bore enlarging tools are employed to enlarge one or more selected section of the anterior or posterior TASIF axial bore(s), e.g., the cephalad bore end or a disc space, so as to provide a recess therein that can be employed for various purposes, e.g., to provide anchoring surfaces for spinal implants inserted into the anterior or posterior TASIF axial bore(s).

CROSS-REFERENCE TO RELATED APPLICATIONS

This is a continuation application of U.S. patent application Ser. No.10/853,476, filed on May 25, 2004, which is a continuation of U.S.patent application Ser. No. 09/710,369, filed on Nov. 10, 2000 andissued as U.S. Pat. No. 6,740,090 on May 25, 2004, which claims priorityand benefits from Provisional Patent Application No. 60/182,748, filedFeb. 16, 2000, titled METHOD AND APPARATUS FOR TRANS-SACRAL SPINALFUSION, all of which are incorporated by reference in their entirety.

FIELD OF THE INVENTION

The present invention relates generally to spinal surgery, particularlymethods and apparatus for forming one or more shaped axial bore throughvertebral bodies in general alignment with a visualized, trans-sacralaxial instrumentation/fusion (TASIF) line in a minimally invasive, lowtrauma, manner.

BACKGROUND OF THE INVENTION

It has been estimated that 70% of adults have had a significant episodeof back pain or chronic back pain emanating from a region of the spinalcolumn or backbone. Many people suffering chronic back pain or an injuryrequiring immediate intervention resort to surgical intervention toalleviate their pain.

The spinal column or back bone encloses the spinal cord and consists of33 vertebrae superimposed upon one another in a series which provides aflexible supporting column for the trunk and head. The vertebraecephalad (i.e., toward the head or superior) to the sacral vertebrae areseparated by fibrocartilaginous intervertebral discs and are united byarticular capsules and by ligaments. The uppermost seven vertebrae arereferred to as the cervical vertebrae, and the next lower twelvevertebrae are referred to as the thoracic, or dorsal, vertebrae. Thenext lower succeeding five vertebrae below the thoracic vertebrae arereferred to as the lumbar vertebrae and are designated L1-L5 indescending order. The next lower succeeding five vertebrae below thelumbar vertebrae are referred to as the sacral vertebrae and arenumbered S1-S5 in descending order. The final four vertebrae below thesacral vertebrae are referred to as the coccygeal vertebrae. In adults,the five sacral vertebrae fuse to form a single bone referred to as thesacrum, and the four rudimentary coccyx vertebrae fuse to form anotherbone called the coccyx or commonly the “tail bone”. The number ofvertebrae is sometimes increased by an additional vertebra in oneregion, and sometimes one may be absent in another region.

Typical lumbar, thoracic and cervical vertebrae consist of a ventral orvertebral body and a dorsal or neural arch. In the thoracic region, theventral body bears two costal pits for reception of the head of a rib oneach side. The arch which encloses the vertebral foramen is formed oftwo pedicles and two lamina. A pedicle is the bony process whichprojects backward or anteriorly from the body of a vertebra connectingwith the lamina on each side. The pedicle forms the root of thevertebral arch. The vertebral arch bears seven processes: a dorsalspinous process, two lateral transverse processes, and four articularprocesses (two superior and two inferior). A deep concavity, inferiorvertebral notch, on the inferior border of the arch provides apassageway or spinal canal for the delicate spinal cord and nerves. Thesuccessive vertebral foramina surround the spinal cord. Articulatingprocesses of the vertebrae extend posteriorly of the spinal canal.

The bodies of successive lumbar, thoracic and cervical vertebraearticulate with one another and are separated by intervertebral discsformed of fibrous cartilage enclosing a central mass, the nucleuspulposus that provides for cushioning and dampening of compressiveforces to the spinal column. The intervertebral discs are anterior tothe vertebral canal. The inferior articular processes articulate withthe superior articular processes of the next succeeding vertebra in thecaudal (i.e., toward the feet or inferior) direction. Several ligaments(supraspinous, interspinous, anterior and posterior longitudinal, andthe ligamenta flava) hold the vertebrae in position yet permit a limiteddegree of movement.

The relatively large vertebral bodies located in the anterior portion ofthe spine and the intervertebral discs provide the majority of theweight bearing support of the vertebral column. Each vertebral body hasrelatively strong bone comprising the outside surface of the body andweak bone comprising the center of the vertebral body.

Various types of spinal column disorders are known and include scoliosis(abnormal lateral curvature of the spine), kyphosis (abnormal forwardcurvature of the spine, usually in the thoracic spine), excess lordosis(abnormal backward curvature of the spine, usually in the lumbar spine),spondylolisthesis (forward displacement of one vertebra over another,usually in the lumbar or cervical spine) and other disorders, such asruptured or slipped discs, degenerative disc disease, fracturedvertebra, and the like. Patients who suffer from such conditions usuallyexperience extreme and debilitating pain and often neurologic deficit innerve function.

Approximately 95% of spinal surgery involves the lower lumbar vertebraedesignated as the fourth lumbar vertebra (“L4”), the fifth lumbarvertebra (“L5”), and the first sacral vertebra (“S1”). Persistent lowback pain is attributed primarily to degeneration of the disc connectingL5 and S1. Surgical procedures have been developed and used to removethe disc and fuse the vertebral bodies together and/or to stabilize theintervertebral structures. Although damaged discs and vertebral bodiescan be identified with sophisticated

diagnostic imaging, the surgical procedures are so extensive thatclinical outcomes are not consistently satisfactory. Furthermore,patients undergoing presently available fusion surgery experiencesignificant complications and uncomfortable, prolonged convalescence.

A number of devices and techniques involving implantation of spinalimplants to reinforce or replace removed discs and/or anterior portionsof vertebral bodies and which mechanically immobilize areas of the spineassisting in the eventual fusion of the treated adjacent vertebrae havealso been employed or proposed over the years In order to overcome thedisadvantages of purely surgical techniques. Such techniques have beenused effectively to treat the above described conditions and to relievepain suffered by the patient. However, there are still disadvantages tothe present fixation implants and surgical implantation techniques. Thehistorical development of such implants is set forth in U.S. Pat. Nos.5,505,732, 5,514,180, and 5,888,223, for example.

One technique for spinal fixation includes the immobilization of thespine by the use of spine rods of many different configurations that rungenerally parallel to the spine. Typically, the posterior surface of thespine is isolated and bone screws are first fastened to the pedicles ofthe appropriate vertebrae or to the sacrum and act as anchor points forthe spine rods. The bone screws are generally placed two per vertebra,one at each pedicle on either side of the spinous process. Clampassemblies join the spine rods to the screws. The spine rods aregenerally bent to achieve the desired curvature of the spinal column.Wires may also be employed to stabilize rods to vertebrae. Thesetechniques are described further in U.S. Pat. No. 5,415,661, forexample.

These types of rod systems can be effective, but require a posteriorapproach and implanting screws into or clamps to each vertebra over thearea to be treated. To stabilize the implanted system sufficiently, onevertebra above and one vertebra below the area to be treated are oftenused for implanting pedicle screws. Since the pedicles of vertebraeabove the second lumbar vertebra (L2) are very small, only small bonescrews can be used which sometimes do not give the needed support tostabilize the spine. These rods and screws and clamps or wires aresurgically fixed to the spine from a posterior approach, and theprocedure is difficult. A large bending moment is applied to such rodassemblies, and because the rods are located outside the spinal column,they depend on the holding power of the associated components which canpull out of or away from the vertebral bone.

In a variation of this technique disclosed in U.S. Pat. Nos. 4,553,273and 4,636,217, both described in U.S. Pat. No. 5,735,899, two of threevertebrae are joined by surgically obtaining access to the interior ofthe upper and lower vertebral bodies through excision of the middlevertebral body. In the '899 patent, these approaches are referred to as“intraosseous” approaches, although they are more properly referred toas “interosseous” approaches by virtue of the removal of the middlevertebral body. The removal is necessary to enable a lateral insertionof the implant into the space it occupied so that the opposite ends ofthe implant can be driven upward and downward into the upper and lowervertebral bodies. These approaches are criticized as failing to provideadequate medial-lateral and rotational support in the '899 patent. Inthe '899 patent, an anterior approach is made, slots are created in theupper and lower vertebrae, and rod ends are fitted into the slots andattached to the remaining vertebral bodies of the upper and lowervertebrae by laterally extending screws.

A number of disc shaped replacements or artificial disc implants andmethods of insertion have been proposed as disclosed, for example, inU.S. Pat. Nos. 5,514,180 and 5,888,223, for example. A further type ofdisc reinforcement or augmentation implant that has been clinicallyemployed for spinal fusion comprises a hollow cylindrical titanium cagethat is externally threaded and is screwed laterally into place in abore formed in the disc between two adjacent vertebrae. Bone grafts fromcadavers or the pelvis or substances that promote bone growth are thenpacked into the hollow center of the cage to encourage bone growth (oringrowth) through the cage pores to achieve fusion of the two adjacentvertebrae. Two such cage implants and the surgical tools employed toplace them are disclosed in U.S. Pat. Nos. 5,505,732 and 5,700,291, forexample. The cage implants and the associated surgical tools andapproaches require precise drilling of a relatively large hole for eachsuch cage laterally between two adjacent vertebral bodies and thenthreading a cage into each prepared hole. The large hole or holes cancompromise the integrity of the vertebral bodies, and if drilled tooposteriorly, can injure the spinal cord. The end plates of the vertebralbodies, which comprise very hard bone and help to give the vertebralbodies needed strength, are usually destroyed during the drilling. Thecylindrical cage or cages are now harder than the remaining bone of thevertebral bodies, and the vertebral bodies tend to collapse or“telescope,” together. The telescoping causes the length of thevertebral column to shorten and can cause damage to the spinal cord andnerves that pass between the two adjacent vertebrae.

Methods and apparatus for accessing the discs and vertebrae by lateralsurgical approaches are described in U.S. Pat. No. 5,976,146. Theintervening muscle groups or other tissues are spread apart by a cavityforming and securing tool set disclosed in the '146 patent to enableendoscope aided, lateral access to damaged vertebrae and discs and toperform corrective surgical procedures.

A compilation of the above described surgical techniques and spinalimplants and others that have been used clinically is set forth incertain chapters of the book entitled Lumbosacral and SpinopelvicFixation, edited by Joseph Y. Margolies et al. (Lippincott-RavenPublishers, Philadelphia, 1996). Attention is directed particularly toChapters 1, 2, 17, 18, 38, 42 and 44. In “Lumbopelvic Fusion” (Chapter38, by Prof. Rene P. Louis, MD) techniques for repairing aspondylolisthesis, in this case, a severe displacement of L5 withrespect to S1 and the intervening disc, are described and depicted. Ananterior lateral exposure of L5 and S1 is made, a discectomy isperformed, and the orientation of L5 to S1 is mechanically correctedusing a reduction tool, if the displacement is severe. A fibula graft ormetal Judet screw is inserted as a dowel through a bore formed extendingcaudally through L5 and into S1. When the screw is used, bone growthmaterial, e.g., bone harvested from the patient, is inserted into thebore alongside the screw, and the disc space is filled with bone suturedto the screw to keep it in place between the vertebral surfaces to actas a spacer implant occupying the extracted disc between L5 and S1.External bridge plates or rods are also optionally installed. Theposterolateral or anterior lateral approach is necessitated to correctthe severe spondylolisthesis displacement using the reduction tool andresults in tissue injury. Because of this approach and need, the caudalbore and inserted the Judet screw can only traverse L5 and S1.

A similar anterior approach for treating spondylolisthesis is disclosedin U.S. Pat. No. 6,056,749. In this approach, a bore hole is formed in acephalad vertebral body and extends through the intervening disc into acaudal vertebral body, the disc is removed, a disk cage is insertedlaterally into the disc space, and an elongated, hollow threaded shaftis inserted into the bore and through a hole in the disc cage. The diskcage takes the place of the harvested bone disc inserts and itsinterlocking intersection with the shaft takes the place of the suturesemployed to tie the harvested bone disc inserts to the screw in thetechnique described in the above-referenced Chapter 38 publication.

The above-described spinal implant approaches involve highly invasivesurgery that laterally exposes the anterior or posterior portions of thevertebrae to be supported or fused. Extensive muscular stripping andbone preparation can be necessary. As a result, the spinal column can befurther weakened and/or result in surgery induced pain syndromes. Thus,presently used or proposed surgical fixation and fusion techniquesinvolving the lower lumbar vertebrae suffer from numerous disadvantages.It is preferable to avoid the lateral exposure to correct less severespondylolisthesis and other spinal injuries or defects affecting thelumbar and sacral vertebrae and discs.

A less intrusive posterior approach for treating spondylolisthesis isdisclosed in U.S. Pat. No. 6,086,589, wherein a straight bore is formedthrough the sacrum from the exposed posterior sacral surface and in aslightly cephalad direction into the L5 vertebral body, preferably afterrealigning the vertebrae. A straight, hollow, threaded shaft with sidewall holes restricted to the end portions thereof and bone growthmaterial are inserted into the bore. A discectomy of the disc between L5and S1 is preferably performed and bone ingrowth material is alsopreferably inserted into the space between the cephalad and caudalvertebral bodies. Only a limited access to and alignment of S1 and L5can be achieved by this approach because the distal ends of the straightbore and shaft approach and threaten to perforate the anterior surfaceof the L5 vertebral body.

A wide variety of orthopedic implants have also been proposed orclinically employed to stabilize broken bones or secure artificial hip,knee and finger joints. Frequently, rods or joint supports are placedlongitudinally within longitudinal bores made in elongated bones, e.g.,the femur. A surgical method is disclosed in U.S. Pat. No. 5,514,137 forstabilizing a broken femur or other long bones using an elongated rodand resorbable cement. To accomplish a placement of a rod into anysingle bone, an end of a bone is exposed and a channel is drilled fromthe exposed end to the other end. Thereafter, a hollow rod is inserted,and resorbable cement is injected through the hollow rod, so as toprovide fixation between the distal end of the rod and the cancelloustissue that surrounds the rod. A cement introducer device can also beused for the injection of cement. A brief reference is made in the '137patent to the possibility of placing rods in or adjacent to the spine inthe same manner, but no particular approach or devices are described.

Drilling tools are employed in many of the above described surgicalprocedures to bore straight holes into the vertebral bones. The boringof curved bores in other bones is described in U.S. Pat. Nos. 4,265,231,4,541,423, and 5,002,546, for example. The '231 patent describes anelongated drill drive shaft enclosed within a pre-curved outer sheaththat is employed to drill curved suture holding open ended bores intobones so that the suture passes through both open ends of the bore. The'423 patent describes an elongated flexible drill drive shaft enclosedwithin a malleable outer sheath that can be manually shaped into a curvebefore the bore is formed. The '546 patent describes a complex curvedrilling tool employing a pivotal rocker arm and curved guide for adrill bit for drilling a fixed curve path through bone. All of theseapproaches dictate that the curved bore that is formed follow thepredetermined and fixed curvature of the outer sheath or guide. Thesheath or guide is advanced through the bore as the bore is made, makingit not possible for the user to adjust the curvature of the bore totrack physiologic features of the bone that it traverses.

SUMMARY OF THE INVENTION

The preferred embodiments of the invention involve methods and apparatusfor forming one or more axial bore through spinal vertebral bodies forperforming surgical procedures for receiving spinal implants, or forother medical reasons wherein the axial bore is shaped with one or morerecess adapted to anchor spinal implants or receive material dispensedtherein or for other purposes.

The preferred embodiments of the present invention involve methods andapparatus including surgical tool sets for first forming an anterior orposterior TASIF axial bore(s) extending from a respective anterior orposterior target point of an anterior or posterior sacral surfacethrough at least one sacral vertebral body and one or more lumbarvertebral body in the cephalad direction. Then, further bore enlargingtools are employed to enlarge one or more selected section of theanterior or posterior TASIF axial bore(s), e.g., the cephalad bore endor a disc space along the bore, so as to provide a recess therein. Therecess can be employed for various purposes, e.g., to provide anchoringsurfaces for spinal implants inserted into the anterior or posteriorTASIF axial bore(s), or to received materials placed into the recessformed in a disc space or vertebral body.

To form an axial bore, the anterior target point on the anterior sacralsurface is accessed using a percutaneous tract extending from a skinincision through presacral space. The posterior target point on theposterior sacral surface is accessed using a surgical exposure of theposterior sacral surface. An anterior axial instrumentation/fusion line(AAIFL) or a posterior axial instrumentation/fusion line (PAIFL) thatextends from the anterior or posterior target point, respectively, inthe cephalad direction following the spinal curvature through one ormore vertebral body is visualized by radiographic or fluoroscopicequipment. Preferably, curved anterior or posterior TASIF axial boresare formed in axial or parallel alignment with the visualized AAIFL orPAIFL, respectively, although the invention is not confined to curvedaxial bores.

When a single anterior or posterior TASIF axial bore is formed, it canbe formed in axial or parallel alignment with the visualized axial AAIFLand PAIFL. Similarly, multiple anterior or posterior TASIF axial borescan be formed all in parallel alignment with the visualized axial AAIFLand PAIFL or with at least one such TASIF axial bore formed in axialalignment with the visualized axial AAIFL and PAIFL.

Moreover, multiple anterior or posterior TASIF axial bores can be formedall commencing at the anterior or posterior target point and extendingin the cephalad direction with each TASIF axial bore diverging apartfrom the other and away from the visualized axial AAIFL and PAIFL. Thediverging TASIF axial bores terminate as spaced apart locations in acephalad vertebral body or in separate cephalad vertebral bodies.

In certain embodiments, small diameter anterior and posterior TASIFaxial bore forming tools can be employed in the same manner to formpilot holes extending in the cephalad direction through one or moresacral and lumbar vertebral bodies in alignment with the visualizedAAIFL and PAIFL. The pilot holes can be used as part of anterior andposterior percutaneous tracts that are subsequently enlarged to form theanterior and posterior TASIF axial bores.

This summary of the invention and the objects, advantages and featuresthereof have been presented here simply to point out some of the waysthat the invention overcomes difficulties presented in the prior art andto distinguish the invention from the prior art and is not intended tooperate in any manner as a limitation on the interpretation of claimsthat are presented initially in the patent application and that areultimately granted.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other advantages and features of the present invention will bemore readily understood from the following detailed description of thepreferred embodiments thereof, when considered in conjunction with thedrawings, in which like reference numerals indicate identical structuresthroughout the several views, and wherein:

FIGS. 1-3 are lateral, posterior and anterior views of the lumbar andsacral portion of the spinal column depicting the visualized PAIFL andAAIFL extending cephalad and axially from the posterior laminectomy siteand the anterior target point, respectively;

FIG. 4 is a sagittal caudal view of lumbar vertebrae depicting a TASIFspinal implant or rod within a TASIF axial bore formed following thevisualized PAIFL or AAIFL of FIGS. 1-3;

FIG. 5 is a sagittal caudal view of lumbar vertebrae depicting aplurality, e.g., 2, TASIF spinal implants or rods within a likeplurality of TASIF axial bores formed in parallel with the visualizedPAIFL or AAIFL of FIGS. 1-3;

FIG. 6 is a simplified flow chart showing the principal surgicalpreparation steps of percutaneously accessing a posterior or anteriortarget point of the sacrum and forming a percutaneous tract followingthe visualized PAIFL or AAIFL of FIGS. 1-3, as well as subsequent stepsof forming the TASIF bore(s) for treatment of accessed vertebral bodiesand intervening discs and of implanting spinal implants therein;

FIG. 7 is a plan view of one exemplary boring tool embodiment comprisingan elongated drill shaft assembly and drill motor for forming a curvedanterior or posterior TASIF axial bore, the drill bit having a 90° curveformed in the elongated drill drive shaft by retraction of an outersheath;

FIG. 8 is a plan view of the boring tool of FIG. 7 with a reducedcurvature formed in the elongated drill shaft assembly by adjustment ofthe outer sheath;

FIG. 9 is a cross-section view of the drill bit of FIGS. 7 and 8 withthe curvature eliminated by full distal extension of the outer sheath tothe distal end of the drill bit;

FIGS. 10-13 illustrate, in partial cross-section side views, one mannerof forming a posterior TASIF axial bore through sacral and lumbarvertebrae and intervening discs axially aligned with the visualizedPAIFL of FIGS. 1 and 2 using the boring tool of FIGS. 7-9;

FIGS. 14-18 illustrate, in partial cross-section side views, one mannerof forming an anterior TASIF axial bore through sacral and lumbarvertebrae and intervening discs axially aligned with the visualizedAAIFL of FIGS. 1 and 2 using the boring tool of FIGS. 7-9;

FIGS. 19-21 illustrate a further exemplary boring tool embodimentcomprising an elongated drill shaft assembly and drill motor for forminga curved anterior or posterior TASIF axial bore in the mannerillustrated in FIGS. 10-18;

FIGS. 22-25 illustrate a still further exemplary boring tool embodimentcomprising an elongated drill shaft assembly and drill motor for forminga curved anterior or posterior TASIF axial bore in the mannerillustrated in FIGS. 10-18;

FIG. 26 depicts, in a partial cross-section side view, the formation ofa plurality of curved TASIF axial bores that diverge apart from a commoncaudal section in the cephalad direction;

FIGS. 27 and 28 depict, in partial cross-section end views taken alonglines 27-27 and 28-28, respectively, of FIG. 26, the divergence of theplurality of curved TASIF axial bores;

FIG. 29 is a partial cross-section side view of a TASIF axial borecounterbored to form an anchoring recess along the caudal end thereof;

FIGS. 30-32 depict a first exemplary embodiment of a counterbore toolfor forming an anchoring recess of the type depicted in FIG. 29;

FIGS. 33-34 depict a second exemplary embodiment of a counterbore toolfor forming an anchoring recess of the type depicted in FIG. 29;

FIGS. 35-36 depict a third exemplary embodiment of a counterbore toolfor forming an anchoring recess of the type depicted in FIG. 29;

FIGS. 37-40 depict a fourth exemplary embodiment of a counterbore toolfor forming an anchoring recess of the type depicted in FIG. 29; and

FIGS. 41-42 depict a second exemplary embodiment of a counterbore toolfor forming an anchoring recess of the type depicted in FIG. 29.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS OF THE INVENTION

The methods and surgical instrumentation and spinal implants disclosedin the above-referenced provisional application No. 60/182,748 and inco-pending, commonly assigned, patent application Ser. No. 09/640,222filed Aug. 16, 2000, for METHOD AND APPARATUS FOR PROVIDING POSTERIOR ORANTERIOR TRANS-SACRAL ACCESS TO SPINAL VERTEBRAE can be employed in thepractice of the present invention. The '222 application discloses anumber of related TASIF methods and surgical tool sets for providingposterior and anterior trans-sacral access to a series of adjacentvertebrae located within a human lumbar and sacral spine having ananterior aspect, a posterior aspect and an axial aspect, the vertebraeseparated by intact or damaged spinal discs. Certain of the tools areselectively employed to form a percutaneous (i.e., through the skin)pathway from an anterior or posterior skin incision to a respectiveanterior or posterior position, e.g., a target point of a sacral surfaceor the cephalad end of a pilot hole bored through the sacrum and one ormore lumbar vertebrae. The percutaneous pathway is generally axiallyaligned with the AAIFL or the PAIFL extending from the respectiveanterior or posterior target point through at least one sacral vertebralbody and one or more lumbar vertebral body in the cephalad direction asvisualized by radiographic or fluoroscopic equipment. The AAIFL andPAIFL follow the curvature of the vertebral bodies that they extendthrough in the cephalad direction.

Attention is first directed to the following description of FIGS. 1-6 istaken from the above-referenced parent provisional application No.60/182,748. The acronyms TASF, AAFL, and PAFL used in the '748application are changed to TASIF, AAIFL and PAIFL in this application toexplicitly acknowledge that instruments can be introduced for inspectionor treatments in addition to the fusion and fixation provided by spinalimplants that may be inserted into the axial bores or pilot holes.

FIGS. 1-3 schematically illustrate the anterior and posterior TASIFsurgical approaches in relation to the lumbar region of the spinalcolumn, and FIGS. 4-5 illustrate the location of the TASIF implant orpair of TASIF implants within a corresponding posterior TASIF axial bore22 or anterior TASIF axial bore 152 or pair of TASIF axial bores 221,222 or 152 ₁, 152 ₂. Two TASIF axial bores and spinal implants or rodsare shown in FIG. 5 to illustrate that a plurality, that is two or more,of the same may be formed and/or employed in side by side relationparallel with the AAIFL or PAIFL. Preferred TASIF surgical approachesfor providing anterior and posterior trans-sacral access depicted inFIGS. 1-3 and preparing the TASIF axial bores 22 or 152 or 22 ₁, 22 ₂,or 152 ₁, 152 ₂ shown in FIGS. 4 and 5 are illustrated in furtherdrawings. Preferred trans-sacral surgical access and TASIF pilot holepreparation tools are depicted in further drawings.

The lower regions of the spinal column comprising the coccyx, fusedsacral vertebrae S1-S5 forming the sacrum, and the lumbar vertebraeL1-L5 described above are depicted in a lateral view in FIG. 1. Theseries of adjacent vertebrae located within the human lumbar and sacralspine have an anterior aspect, a posterior aspect and an axial aspect,and the lumbar vertebrae are separated by intact or damaged spinal discslabeled D1-D5 in FIG. 1. FIGS. 2 and 3 depict the posterior and anteriorview of the sacrum and coccyx.

The method and apparatus for forming an anterior or posterior TASIFaxial bore initially involves accessing an anterior sacral position,e.g. an anterior target point at the junction of S1 and S2 depicted inFIGS. 1 and 3, or a posterior sacral position, e.g. a posteriorlaminectomy site of S2 depicted in FIGS. 1 and 2. One (or more)visualized, imaginary, axial instrumentation/fusion line extendscephalad and axially in the axial aspect through the series of adjacentvertebral bodies to be fused, L4 and L5 in this illustrated example. Thevisualized AAIFL through L4, D4, L5 and D5 extends relatively straightfrom the anterior target point along S1 depicted in FIGS. 1 and 3, butmay be curved as to follow the curvature of the spinal column in thecephalad direction. The visualized PAIFL extends in the cephaladdirection with more pronounced curvature from the posterior laminectomysite of S2 depicted in FIGS. 1 and 2.

It should be noted that the formation of the anterior tract 26 throughpresacral space under visualization described above is clinicallyfeasible as evidenced by clinical techniques described by J. J.Trambert, MD, in “Percutaneous Interventions in the Presacral Space:CT-guided Precoccygeal Approach—Early Experience (Radiology 1999;213:901-904).

FIG. 6 depicts, in general terms, the surgical steps of accessing theanterior or posterior sacral positions illustrated in FIGS. 1-3 (S100)forming posterior and anterior TASIF axial bores (S200), optionallyinspecting the discs and vertebral bodies, performing disc removal, discaugmentation, and vertebral bone reinforcement (S300), and implantingposterior and anterior spinal implants and rods (S400) in a simplifiedmanner. In step S100, access to the anterior or posterior sacralposition, that is the anterior target point of FIG. 3 or the posteriorlaminectomy site of FIG. 2 is obtained, and the anterior or posteriorsacral position is penetrated to provide a starting point for each axialbore that is to be created. Then, an axial bore is bored from each pointof penetration extending along either the PAIFL or AAIFL cephalad andaxially through the vertebral bodies of the series of adjacent vertebraeand any intervertebral spinal discs (S200). The axial bore may bevisually inspected using an endoscope to determine if the procedures ofstep S300 should be performed. Discoscopy or discectomy or discaugmentation of an intervening disc or discs or vertebroblasty of avertebral body may be performed through the axial bore (S300). Finally,an elongated TASIF spinal implant or rod is inserted into each axialbore to extend cephalad and axially through the vertebral bodies of theseries of adjacent vertebrae and any intervertebral spinal discs (S400).Other types of spinal implants for delivering therapies or alleviatingpain as described above may be implanted in substitution for step S400.

Step S100 preferably involves creation an anterior or posteriorpercutaneous pathway that enables introduction of further tools andinstruments for forming an anterior or posterior percutaneous tractextending from the skin incision to the respective anterior or posteriortarget point of the sacral surface or, in some embodiments, the cephaladend of a pilot hole over which or through which further instruments areintroduced as described in the above-referenced '222 application. An“anterior, presacral, percutaneous tract” extends through the “presacralspace” anterior to the sacrum. The posterior percutaneous tract or theanterior, presacral, percutaneous tract is preferably used to bore oneor more respective posterior or anterior TASIF bore in the cephaladdirection through one or more lumbar vertebral bodies and interveningdiscs, if present. A single anterior or posterior TASIF bore ispreferably aligned axially with the respective visualized AAIFL orPAIFL, and plural anterior or posterior TASIF bores are preferablyaligned in parallel with the respective visualized AAIFL or PAIFL.Introduction of spinal implants and instruments for performingdiscectomies and/or disc and/or vertebral body augmentation is enabledby the provision of the percutaneous pathway and formation of theanterior or posterior TASIF bore(s).

It should be noted that performing step S100 in the anterior and/orposterior TASIF procedures may involve drilling a pilot hole, smaller indiameter than the TASIF axial bore, that tracks the AAIFL and/or PAIFLin order to complete the formation of the anterior and/or posteriorpercutaneous tracts. Step S300 may optionally be completed through theAAIFL/PAIFL pilot hole following step S100, rather than following theenlargement of the pilot hole to form the TASIF axial bore in step S200.

The preferred embodiments of the present invention involve methods andapparatus including surgical tool sets for forming pilot holes orcurved, posterior and anterior, TASIF axial bores 22 or 152 or 22 ₁ . .. 22 _(n), or 152 ₁ . . . 152 _(n) shown in FIGS. 4 and 5 in axialalignment with the curved, visualized AAIFL and PAIFL. The surgical toolsets comprise elongated drill shaft assemblies supporting distal boringtools, e.g., mechanical rotating drill bits, burrs, augurs, abraders, orthe like (collectively referred to as drill bits for convenience) thatcan be manipulated in use to straighten or form a selected curvature ina distal section or segment of each elongated drill shaft assembly. Whenthe distal segment is straightened, the drill bit bores straight aheadto bore a relatively straight section of the TASIF axial bore. Then,when the distal segment is curved, the drill bit bores the next sectionof the TASIF axial bore at an angle to the previously drilled, morecaudal section of the TASIF axial bore. The cumulative effect of boringalternate straight and curved sections results in an overall curvaturein the TASIF axial bore that tracks the AAIFL or PAIFL as describedabove.

A First Exemplary Boring Tool:

FIGS. 7 -9 show one exemplary boring tool 10 for boring a single one ora plurality of curved anterior or posterior TASIF axial bores alignedwith the curved, visualized AAIFL or PAIFL as illustrated in FIGS.10-18. The boring tool 10 comprises an elongated drill shaft assembly 12and a drill motor 30 (shown in part) which may take any form. It will beunderstood that the drill motor 30 can be permanently attached to andform part of the proximal end of the elongated drill shaft assembly 12,but is depicted herein as a separate, detachable drill motor. Theelongated drill shaft assembly 12 extends between an exposed proximaldrive shaft end 14 at the proximal drill shaft assembly end 18 anexposed drill bit 20 at the distal drill shaft assembly end 24. Theexposed proximal drive shaft end 14 is received within and attached to achuck 32 of drill motor 30 in a manner well known in the art to rotatethe drive shaft 26 extending from the drive shaft proximal end throughthe length of the elongated drill shaft assembly to the exposed distaldrill bit 20. The exposed distal drill bit 20 may take any form of burror auger or screw that can be rotated at a suitable speed to penetratethe dense and hard outer periostium and compact bone layers of thevertebral bodies and advance through the relatively softer, interiorlydisposed, spongy bone. Then, the drill bit 20 is advanced in a curvedpath in the cephalad direction perforating each opposed face of eachvertebral body and intervening disc while staying within the spongy boneof each vertebral body that is penetrated. The drill bit 20 ispreferably radiopaque so that its advancement through vertebral bodiescan be observed employing conventional imaging equipment.

The elongated drill shaft assembly 12 further comprises a pre-curvedinner sheath 34 having an inner sheath lumen 36 receiving and enclosingthe drive shaft 26, an outer sheath 40 having an outer sheath lumen 42enclosing the inner sheath 34, and a housing 16 that is attached to theproximal end of the inner sheath 34. The outer sheath 40 can beretracted proximally over the inner sheath 34 so that a distal segmentof the inner sheath 34 is exposed or extended distally over the innersheath 34 so that the distal segment thereof is enclosed within theouter sheath lumen 42.

The drive shaft 26 is flexible and bendable and can formed of a singlefilament or multi-filar straight or coiled wire and is preferablyradiopaque so that it can be observed using conventional imagingequipment. The distal end of the drive shaft 26 is attached to the drillbit 20 by in any manner, e.g., by welding to a proximal surface thereofor by being crimped inside a crimp tube lumen of a proximally extendingcrimp tube 44 of the drill bit 20 as shown in FIG. 9. The proximal endof the drive shaft 36 is received within a further crimp or weld tube 46that extends distally from the proximal exposed drive shaft end 14 asshown in FIG. 9. The proximal exposed drive shaft end extends through abearing in the proximal end wall of the housing 16 and is supportedthereby for rotation by motor 30.

The outer diameters of the housing 16 and the drill bit 20 exceed theouter diameter of the straight outer sheath 40. The straight outersheath 40 can be moved back and forth over the pre-curved inner sheath34 between a proximal position depicted in FIG. 7, a distal positiondepicted in FIG. 9 and any number of intermediate positions bounded bythe housing 16 and drill bit 20.

The straight outer sheath 40 is preferably formed of a stiff metal orplastic tube that is relatively stiffer and shorter in length than themore flexible, pre-curved inner sheath 34. The more flexible, pre-curvedinner sheath 34 can be formed of a plastic or metal thin walled tubingand is pre-curved in a single plane to a suitable angle, e.g., about a90° angle, in the distal segment thereof as shown in FIG. 7. The angleand radius of curvature of the distal segment can be selected along withthe length and stiffness of the outer sheath 40 to meet the needs oftracking the AAIFL or the PAIFL. The stiffness of the outer sheath 40 isselected to enable it to be advanced distally to straighten thecurvature of the distal segment of the inner sheath 34. However, theouter sheath 40 is flexible enough that it can be bent or curved withinthe confines of the curved TASIF axial bores as it is formed by thedrill bit. In this way, the outer sheath can be advanced in the cephaladdirection or retracted in the caudal direction and still conform to thecurvature of the curved TASIF axial bore.

Posterior TASIF Axial Bore Formation:

FIGS. 10-13 show steps included in step S200 for forming a posteriorTASIF axial bore 22 through sacral and lumbar vertebrae and interveningdiscs axially aligned with the visualized PAIFL of FIGS. 1 and 2 usingthe boring tool of FIGS. 7-9. The same steps can be employed to form apilot hole of step S100 that can be enlarged in step S200. Using thistechnique to form the posterior TASIF axial bore, a small diameter boreforming tool (e.g. 3.0 mm diameter) is used to first bore a smalldiameter curved pilot hole following the imaginary, visualized PAIFL 20through S1, L5 and L4. Then, the boring tool is removed, and a guidewirehaving a threaded distal screw-in tip is advanced through the pilot holeand screwed into to the caudal end of the pilot hole and into cephaladportion of the L4 body. An over-the-wire bore enlarging tool having aflexible body capable of tracking the curved guidewire is fitted overthe proximal end of the guidewire and manually or mechanically rotatedand advanced along it. In this way, the small pilot hole diameter isenlarged to form the anterior TASIF axial bore 22 having a diameter e.g.a 10.0 mm diameter, and the enlarging tool is then removed.

It will be understood that the illustrated diameter of the posteriorTASIF axial bore hole 22 relative to sizes of the vertebral bodies ismerely exemplary, and that it is contemplated that the pilot holes andbore hole diameters can range from range from about 1-10 mm and 3-30 mm,respectively. Moreover, it will be understood that a plurality of suchposterior TASIF axial bores 22 ₁ . . . 22 _(n) can be formed in side byside relation generally aligned with the PAIFL.

In FIG. 10, the posterior surface of the sacrum is exposed in step S100as described in the above-referenced '222 and '748 applications. Thearea of the patient's skin surrounding the incision site is surgicallyprepped, and the anus is excluded from the surgical field using adhesivedrapes. The actual dermal entry site may be determined by the prone,preoperative CT scan or MRI study that maps the PAIFL. In step S100, anincision is made in the patient's skin over the posterior sacral surfaceof S2, and the subcutaneous tissue is separated to expose theposteriorly extending, bony ridge of the posterior sacral surface. Asmall laminectomy 14 is performed through the posterior ridge of thesacrum inferior. The thecal sac and nerve roots that are exposed by thelaminectomy are gently retracted, and the terminal portion of the spinalcanal is exposed.

The elongated drill shaft assembly 12 is axially aligned with the PAIFLat the posterior target point so that the initial penetration of thesacrum is substantially at right angles to the exposed sacral surface. Adrill guide for receiving the drill drive shaft assembly for drilling orboring a TASIF axial bore from S2 along the visualized PAIFL 20 mayoptionally be attached to S2 and extended posteriorly through theexposed spinal canal and skin incision. In this starting position, thestraight outer sheath 40 is fully distally extended to straighten theinner sheath 34, and the drill bit 20 is rotated to commence boring aposterior TASIF axial bore 22. The elongated drill shaft assembly 12thus advances anteriorly to form a straight segment or section of theposterior TASIF axial bore 22.

The progress of the drill bit 20 is observed using conventional imagingequipment. As the elongated drill shaft assembly 12 is extendedanteriorly, it is necessary to retract the straight outer sheath 34proximally to allow the inner sheath to curve in the cephalad directionto introduce a curvature in the cephalad segment of the posterior TASIFaxial bore 22 as shown in FIG. 11. It is also necessary to orient andhold the proximal housing 16 so that the plane of curvature of thedistal segment is aligned to the axis of the spine. The degree ofcurvature of the cephalad segment of the posterior TASIF axial bore 22is continually adjusted by incremental proximal and distal movements ofthe straight outer sheath 40 at flange 50 to expose more or less of thedistal segment of the curved inner sheath 34 as shown in FIG. 12. Inthis way, the drill bit 20 advances through the sacral vertebrae in thecephalad direction and toward the lumbar vertebral bodies while stayingwithin the spongy bone of each vertebral body. Theoretically, any numberof vertebral bodies of the spine can be bored through in the cephaladdirection.

Anterior TASIF Axial Bore Formation:

FIGS. 14-16 show steps included in step S200 for forming an anteriorTASIF axial bore 152 through sacral and lumbar vertebrae and interveningdiscs axially aligned with the visualized AAIFL of FIGS. 1 and 2 usingthe boring tool of FIGS. 7-9. The same steps can be employed to form apilot hole of step S100 that can be enlarged in step S200. It will beunderstood that the illustrated diameter of the anterior TASIF axialbore hole 152 relative to sizes of the vertebral bodies is merelyexemplary, and that it is contemplated that the pilot holes and borehole diameters can range from about 1-10 mm and 3-30 mm, respectively.Moreover, it will be understood that a plurality of such anterior TASIFaxial bores 152 ₁ . . . 152 _(n) can be formed in side by side relationgenerally aligned with the AAIFL.

In FIG. 14, the elongated drill shaft assembly 12 is axially alignedwith the AAIFL at the anterior target point so that the initialpenetration of the sacrum is substantially at right angles to theopposed faces of S1 and L5 cephalad to the sacral surface ofpenetration. This anterior sacral surface starting point is accessed instep S100 from an incision in the patient's skin alongside the coccyxand via a percutaneous tract formed in the pre-sacral space which may ormay not include a tract forming structure or tool as disclosed in theabove-referenced '222 and '748 applications.

In this starting position, the straight outer sheath 40 is either fullydistally extended to straighten the inner sheath 34 or retractedslightly depending on the patient's anatomy to provide an optimalorientation to the AAIFL. The drill bit 20 is rotated to commence boringan anterior TASIF axial bore 152, and the elongated drill shaft assembly12 advances anteriorly to form a relatively straight or slightly curvedsegment of the posterior TASIF axial bore 22.

Again, the progress of the drill bit 20 is observed using conventionalimaging equipment. As the elongated drill shaft assembly 12 is extendedin the cephalad direction through S1, D5 (if present) and L5, it becomesnecessary to retract the straight outer sheath 34 proximally to allowthe inner sheath to curve in the cephalad direction to introduce agreater degree of curvature in the cephalad segment of the anteriorTASIF axial bore 152 as shown in FIG. 15. Again, it is also necessary toorient and hold the proximal housing 16 so that the plane of curvatureof the distal segment is aligned to the axis of the spine. This could beaccomplished using external reference markings on the proximal housing16. The degree of curvature of the cephalad segment of the anteriorTASIF axial bore 152 is continually adjusted by incremental proximal anddistal movements of the straight outer sheath 40 at flange 50 to exposemore or less of the distal segment of the curved inner sheath 34 asshown in FIG. 15. In this way, the drill bit 20 advances through thesacral vertebrae in the cephalad direction and through the lumbarvertebral bodies while staying within the spongy bone of each vertebralbody.

Slight but abrupt angular changes in the overall curvature of theanterior TASIF axial bore 152 are made within the vertebral bodies of L5and L4 as shown in FIGS. 15 and 16, by caudal retraction of the outersheath 40 and cephalad advancement of inner sheath 34. It is expectedthat it will usually be easier to adjust the angle of the drill bit 20within the spongy bone interior to the vertebral bodies than in the discspace or while boring through the harder exterior vertebral bone.Therefore, after the spongy interior bone is bored through, the outersheath 40 is advanced in the distal direction to straighten the angle ofadvancement of the drill bit 20 through the harder vertebral bone oneither side of the disc. This straightened boring angle of attack isshown in FIG. 17, for example, where the drill bit 20 is advanced acrossthe opposed faces of vertebral bodies L4 and L5 with the outer sheath 40fully advanced in the cephalad direction. This process results in shortrelatively straight sections separated by more curved sections of the ofthe anterior TASIF axial bore 152. Thus, the resulting anterior TASIFaxial bore 152 shown in FIG. 18 exhibits an overall curvature trackingthe spinal curvature and the visualized AAIFL, but the curve radiusvaries, showing a shorter radius within the central portions ofvertebral bodies L5 and L4.

A Further Exemplary Boring Tool

FIGS. 19-21 illustrate a further embodiment of an exemplary boring tool110 comprising a drill motor 30 and an elongated drill shaft assembly112 employing one or more tip deflection wire 104 (FIG. 21) forimparting a desired curvature in the distal segment of sheath 134. Thesheath 134 extends from the distal end 124 into the housing 124 in themanner of sheath 34 depicted in FIG. 9, but it encloses an inner lumen136 for receiving the drive shaft 126 and a radially offset tipdeflection wire lumen 102 receiving a tip deflection wire 104. Thedistal end of the drive shaft 126 is attached to the drill bit 120 inthe manner described above for attachment of the distal end of driveshaft 26 with the drill bit 20. The proximal end of the drive shaft 126is attached to the proximal exposed drive shaft end 114 in the mannerthat the proximal end of the drive shaft 26 is attached to the proximalexposed drive shaft end 14. The drive shaft 126 may take any formincluding the depicted coiled wire form with or without a core wireextending through the coiled wire lumen.

The tip deflection wire 104 extends through the wire lumen extendingalong one side of the drive shaft sheath 134 between an attachment pointat the distal end 124 and an attachment within housing 138 with distalsegment curvature control ring 106 mounted on housing 138. The distalsegment of drive shaft sheath 134 distal to junction 136 is moreflexible than the proximal segment of drive shaft sheath 134 proximal tojunction 136. The distal segment curvature control ring 106 is locatedover the cylindrical surface of housing 138, and an inwardly extendingmember extends into an elongated groove 108 in the housing 138 where itis attached to the proximal end of the tip deflection wire 104. Theretraction of tip deflection wire 104 to form the curves in the driveshaft distal segment depicted in FIGS. 19 and 20 is effected by slidingthe control ring 106 proximally from a rest or neutral position whereinthe distal segment assumes a straight distal segment shape 134′ asdepicted in broken lines in FIG. 19. It will be understood that thelength of the distal segment of the drive shaft 126 and the range ofmotion of the control ring 106 from the neutral position can be selectedso as to form any angle or range of curvature that may be founddesirable. Furthermore, it will be understood that the range of motionof the control ring 106 from the neutral position can be selected suchthat the control ring may be pushed distally from the neutral positionto impart a curvature in the distal segment that is opposite to thecurvatures depicted in FIGS. 19 and 20. The tip deflection wire 104 cantherefore be either a pull wire for retraction only or a push-pull wirefor retraction and extension.

The boring tool 110 can be employed to form the posterior and anteriorTASIF axial bores 22 and 152 or a plurality of the same in the samemanner as described above with respect to FIGS. 10-18. The curvature ofthe posterior and anterior TASIF axial bores 22 and 152 is controlled bymanipulation of the distal segment curvature control ring 106 as thedrill bit 120 is advanced in the cephalad direction from the startingpoints depicted in FIGS. 10 and 14.

A Still Further Exemplary Boring Tool:

FIGS. 22-25 illustrate a further embodiment of an exemplary boring tool210 comprising a drill motor 230 and an elongated drill shaft assembly212. The elongated drill shaft assembly 212 further comprises a straightinner sheath 234 having an inner sheath lumen 236 receiving andenclosing the drive shaft 226, a straight outer sheath 240 having anouter sheath lumen 242 enclosing the inner sheath 234, and a housing 238that is attached to the proximal end of the inner sheath 234. In thisembodiment, the inner sheath 234 is optional and can be eliminated toreduce the overall diameter of the elongated drill shaft assembly 212.

The drive shaft 226 is flexible and bendable enough to be either bestraight when extended distally or curved in use as described below andcan formed of a single filament or multi-filar straight or coiled wirethat is preferably radiopaque so that it can be observed usingconventional imaging equipment. The distal end of the drive shaft 226 isattached to the spherical drill bit 220 by in any manner, e.g., bywelding to a proximal surface thereof or by being crimped inside a crimptube lumen of a proximally extending crimp tube 244 of the drill bit 220as shown in FIG. 23. The proximal end of the drive shaft 236 is receivedwithin a further crimp or weld tube 246 that extends distally from theproximal exposed drive shaft end 214 as shown in FIG. 23. The proximalexposed drive shaft end 214 extends through a bearing in the proximalend wall of the housing 238 and is supported thereby for rotation bymotor 30.

The flexible outer sheath 240 is generally circular in cross-section andextends between a push-pull proximal handle 250 and a distal endthereof. The outer sheath lumen 242 is radially offset from the axis ofthe flexible outer sheath 240 so that the drill shaft 226 and optionalinner sheath 234 extend through the outer sheath lumen to locate thedrill bit 220 offset from the axis of the flexible outer sheath 240 asshown in FIGS. 23 and 24. A sleeve-shaped, thrust bearing 228 formed ofa hard plastic or metal material is disposed in the outer sheath distalend surrounding the distal end opening of the outer sheath lumen 242 andprojecting slightly distally therefrom. The remaining exposed portion ofthe outer sheath 240 is flexible and compressible to be advanced througha bore hole formed by the drill bit 220. The outer diameters of thehousing 238 and the drill bit 220 exceed the outer diameter of theflexible outer sheath 240. The flexible outer sheath 240 can be movedback and forth over the inner sheath 234 between a proximal positiondepicted in FIG. 22 and a distal position depicted in FIG. 25. The outerdiameter of the drill bit 220 is approximately equal to or slightlylarger than the outer diameter of the outer sheath 240 as shown in FIGS.23 and 24.

A curvature in the distal segment of the outer and inner sheaths 240 and234 toward the radial offset direction D (FIG. 23) is formed when theouter sheath 240 is advanced distally to its full extent as shown inFIG. 25. The distal surface of the thrust bearing 228 bears against theproximal spherical surface of the drill bit 220 when force is applied bypushing the outer sheath 240 distally at handle 250 and/or pulling theinner sheath 234 proximally at housing 238. The axial offset of theouter sheath lumen 242 and the flexibility of the outer sheath 240 justproximally to thrust bearing 228 cooperate to laterally deflect thedrill bit 220 toward the radial offset direction D. The thinner wall ofthe outer sheath 240 in the radial offset direction contributes to itsaxial compression and inducement of the depicted curvature. It will beunderstood that the angular deflection of the drill tip 220 and therange of curvature of the distal segment of the outer and inner sheaths240 and 234 toward the radial offset direction D can be selected by theselection of materials and the offset of the outer sheath lumen 242 fromthe axis of outer sheath 240.

The boring tool 210 can be employed to form the posterior and anteriorTASIF axial bores 22 and 152 or a plurality of the same in the samemanner as described above with respect to FIGS. 10-18. The curvature ofeach section of the posterior and anterior TASIF axial bores 22 and 152is controlled by proximal and distal manipulation of the outer sheath240 with respect to inner sheath 234 as the drill bit 220 is advanced inthe cephalad direction from the starting points depicted in FIGS. 10 and14.

It will be understood that the above-described embodiments of TASIFaxial bore or pilot hole boring tools can be modified in many ways. Forexample, the elongated drive shaft assemblies can be modified to providefluid lumens for pumping flushing fluids into the TASIF axial bores atthe distal ends thereof and for conveying flushing fluid and bonefragments proximally to the exterior of the patient's body. Also, theelongated drive shaft assemblies can be modified to provide a guide wirelumen extending from the proximal to the distal ends thereof foradvancement over a guidewire. Suitable drive motors for rotating a driveshaft over a guidewire and drive shaft assemblies having flushingcapabilities are disclosed in U.S. Pat. No. 6,066,152, for example.

When a single posterior or anterior TASIF axial bore 22 or 152 isformed, it can be formed in axial or parallel alignment with thevisualized axial AAIFL and PAIFL as described. Similarly, multipleposterior or anterior TASIF axial bores can be formed all in parallelalignment with the visualized axial AAIFL and PAIFL or with at least onesuch TASIF axial bore formed in axial alignment with the visualizedaxial AAIFL and PAIFL.

Diverging TASIF Axial Bores:

Moreover, multiple anterior or posterior TASIF axial bores can be formedall commencing at an anterior or posterior target point of FIGS. 1-3 andextending in the cephalad direction with each TASIF axial bore divergingapart from the other and away from the visualized axial AAIFL and PAIFL.The diverging TASIF axial bores terminate as spaced apart locations in acephalad vertebral body or in separate cephalad vertebral bodies.

For example, FIGS. 25-27 depict a group of three anterior TASIF axialbores 152 ₁, 152 ₂, 152 ₃ that are bored from a common caudal entrancebore section 152′ starting at the anterior target point and extending inthe cephalad direction generally following the curvature of the AAIFLbut diverging outwardly. the divergence from the common entry boresection can start in the sacral vertebra or in L5 or in L4 or in anyother cephalad vertebra that the bore extends into or through. A“tripod” of the diverging TASIF axial bores 152 ₁, 152 ₂, 152 ₃ isformed as shown in FIGS. 26 and 27. The common caudal entrance boresection 152′ through S1, and traversing disc D5 and part of L4 can belarger in diameter than the diverging TASIF axial bores 152 ₁, 152 ₂,152 ₃ to accommodate the insertion of three elongated spinal implantstherein. It is believed that the insertion of elongated spinal implantswithin the “tripod” of the diverging TASIF axial bores 152 ₁, 152 ₂, 152₃ can substantially strengthen and enhance fusion of L4, L5 and S1. Thediverging TASIF axial bores 152 ₁, 152 ₂, 152 ₃ can be extended furtherthan shown in FIGS. 25-27.

Counterbored Recesses for Anchoring Spinal Implants:

Thus, the above-described tool sets can be employed to bore a curvedtrans-sacral axial bore or pilot hole in alignment with said axialfusion line cephalad and axially through the vertebral bodies of saidseries of adjacent vertebrae and any intervertebral spinal discs. Thealignment can be axial alignment as shown in FIG. 4, or parallel asshown in FIG. 5 or diverging alignment as shown in FIGS. 25-27. Theabove described tool sets can also be employed to form relativelystraight trans-sacral axial bores through a sacral vertebra and at leastone cephalad lumbar vertebra. Recesses are formed in the relativelystraight or curved trans-sacral bores in a accordance with the presentinvention.

The recesses preferably extend outward into the vertebral bone or intothe intervertebral discs so that anchoring surfaces are formed that aregenerally normal or at an angle to the axis of the anterior or posteriorTASIF axial bore(s) 22 or 152 traversing the recesses. The anchoringsurfaces accommodate outwardly extending anchor portions or structuresof the elongated spinal implants to maintain them in position within theanterior or posterior TASIF axial bore(s) 22 or 152.

FIG. 29 illustrates an anterior TASIF axial bore 152 extending intovertebral body L3, for example, where a counterbore recess 154 ofgreater diameter than the diameter of the anterior TASIF axial bore 152is formed within the cancellous bone. It will be understood that thecounterbore recess 154 can be formed having an annular anchoring surface156 extending outwardly from the anterior TASIF axial bore 152. Thedepicted counterbore recess 154 is formed in a cylindrical barrel shape,but it will be understood the shape can be more spherical orhemispherical. depending upon the tool employed to form it. It isexpected that recesses 154 can be formed both at the cephalad end of theTASIF axial bore as depicted in FIG. 29 and in more caudal vertebralbodies.

Moreover, it is anticipated that one or more recess can be formedextending into the intervertebral disc space, e.g. at disc D5 or D4 orD3 depicted in FIG. 29. For example, a disc recess 154′ is depicted indisc D4. The disc recess 154′ can be wholly within the disc D4, exposingthe opposed vertebral body faces of L5 and L4 or extend in to the boneof L5 and/or L4.

A wide variety of tools having bore enlarging cutting heads can beemployed to counterbore the recess 154, 154′, as long as they can bedelivered and operated through the anterior TASIF axial bore(s) orposterior TASIF axial bore(s) 22. It is necessary that the cutting headbe delivered to the cephalad end or other site of the axial bore by wayof an elongated flexible counterbore drive shaft that can conform to thecurvature of the axial bore. The flexible tool drive shaft would bedriven, typically rotated, within the confines of the axial bore tocause the cutting tool to counterbore the recess 154, 154′ at theselected site. The elongated flexible counterbore drive shaft and distalcutting tool can be delivered directly through the axial bore and guidedthereby to the selected location for forming a recess. Or, they can bedelivered through a flexible protective outer sheath and/or over aguidewire previously placed and attached to vertebral bone at thecephalad end of the axial bore. Then, the cutting tool is deployed atthe selected site, preferably by rotation through the flexible tooldrive shaft or through manipulation of a deployment wire or the like, toextend outward of the axial bore. The flexible tool drive shaft is thenrotated by a drive motor attached to its proximal end outside thepatient's body to rotate the cutting tool to cut or abrade away thecancellous bone or disc body thereby enlarging the bore diameter tocounterbore the recess. After the recess is formed, the cutting tool isretracted by manipulation of a deployment wire or automatically when thedrive motor is turned off. For simplicity, the following descriptions ofpreferred counterbore tools describe forming recess 154 within avertebral body, but apply as well to forming a disc recess 154′.

A First Exemplary Counterbore Tool:

FIGS. 30-32 depict one such motor driven recess forming tool 400comprising the schematically depicted drive motor 402 coupled to theproximal end of a drive shaft 404 within the lumen 406 of an elongatedflexible sheath 410. The drive shaft 404 is formed with a drive shaftlumen 412 enclosing a pull wire 414 that extends proximally from thedrive shaft connection with the drive motor 402 through the drive motor402 to a proximal pull wire manipulator 416 A cutting head 420 having acutting tool lumen is attached to and extends distally from the driveshaft distal end 418 to a cutting tool distal end 422. The distal end ofthe pull wire 414 extends from the distal end opening of the drive shaftlumen through the cutting tool lumen and to a fixed connection with thecutting tool distal end 422.

The cutting head 420 is formed of a thin flexible metal tube that isslit lengthwise into a number N cutting tool bands 424 ₁ to 424 _(n).The N cutting tool bands 424 ₁ to 424 _(n) are spring-like and normallyare straight as depicted in FIG. 30. The recess forming tool 400 isinserted through the posterior or anterior TASIF axial bore 22 or 152 toa selected site, e.g., the cephalad end within the most cephalad lumbarvertebral body, in the configuration depicted in FIG. 30.

Then, pull wire 414 is pulled proximally from proximal manipulator 416and fixed at a first retracted position to commence counter boring therecess within the soft spongy cancellous bone of the vertebral body. Thepull wire 414 pulls the cutting tool distal end 422 proximally causingthe N cutting tool bands 424 ₁ to 424 _(n) to bow outward as shown inFIG. 31. Then the pull wire proximal manipulator 416 is locked inposition, e.g., by a chuck mechanism, and the drive motor 402 isenergized to rotate the cutting head 420 through mutual rotation of thedrive shaft 404 and the pull wire 414. The sharp edges of the cuttingtool bands 424 ₁ to 424 _(n) cut away the surrounding vertebral bone,and the cutting tool bands 424 ₁ to 424 _(n) expand further outwarduntil the rotation is halted. The pull wire 414 can be pulled back moreproximally and set again to expand the cutting tool bands 424 ₁ to 424_(n) outward further as shown in FIG. 32 If further enlargement of therecess is desired.

The rotation of the cutting tool bands 424 ₁ to 424 _(n) is halted whena desired size of the recess is achieved. The pull wire 414 is thenreleased to restore the cutting head 420 to the straight shape depictedin FIG. 30. The cutting tool 400 is either retracted completely from oris retracted to a more caudal location within the posterior or anteriorTASIF axial bore 22 or 152 to counterbore a more caudal counterborerecess in the same manner as described above.

The cutting tool 400 can be varied in many respects, e.g., by changingthe shape, length, number and materials used for the cutting tool bands424 ₁ to 424 _(n). Moreover, it would be possible to employ a push wireto push the cutting tool bands 424 ₁ to 424 _(n) from the configurationof FIG. 30 to the outwardly expanded configurations of FIGS. 31 and 32.

In addition, the proximal manipulator 416 can be replaced by a materialfeed length metering tool that automatically pulls the pull wire 414 (orpushes in the case of a push wire) until resistance is met when thedrive motor 402 is de-energized to increase the outward expansion of thecutting tool bands 424 ₁ to 424 _(n).

A Second Exemplary Counterbore Tool:

A further cutting tool 500 is depicted in FIGS. 33 and 34, wherein theschematically depicted drive motor 502 is coupled to the proximal end ofa drive shaft 504 within the lumen 506 of an elongated flexible sheath510. The drive shaft 504 is formed with a drive shaft lumen 512enclosing a push wire 514 that extends proximally from the drive shaftconnection with the drive motor 502 through the drive motor 502 to aproximal push wire manipulator 516. A cutting head 520 having a cuttingtool lumen is attached to and extends distally from the drive shaftdistal end 518 to a cutting tool distal end 522.

The cutting head 520 is formed of a thin flexible metal tube that isslit lengthwise to form a gap 532, and a cutting tool wire or band 524extends the length of the gap 532. The distal end of the cutting toolwire or band is fixed to the interior of the cutting head 520 at or nearthe distal end 522. The distal end of the push wire 514 is attached tothe proximal end of the cutting tool wire or band 524 within the driveshaft lumen 512. The cutting tool wire or band 524 is spring-like andnormally is straight when push wire manipulator 516 is pulled proximallyas depicted in FIG. 33. The recess forming tool 500 is inserted throughthe posterior or anterior TASIF axial bore 22 or 152 to a selected site,e.g., the cephalad end within the most cephalad lumbar vertebral body,in the configuration depicted in FIG. 33.

Then, push wire 514 is pushed distally from proximal manipulator 516 andfixed at an extended position to commence counter boring the recesswithin the soft spongy cancellous bone of the vertebral body. The pushwire 514 pushes the cutting wire or band 524 out of the gap 532 as shownin FIG. 34. The cutting wire or band 524 may be formed of a material,e.g., a superelastic metal alloy, and have a number of pre-formed bendsor angles so that it forms a more squared off extended profile asdepicted in FIG. 34. Then, the push wire proximal manipulator 516 islocked in position, e.g., by a chuck mechanism, and the drive motor 502is energized to rotate the cutting head 520 through mutual rotation ofthe drive shaft 504 and the push wire 514. The sharp edges of thecutting tool wire or band 524 cuts away the surrounding vertebral bone,and the cutting tool wire or band 524 expands further outward until therotation is halted. The push wire 514 can be pushed more distally andset again to expand the cutting tool band or wire 524 outward further Iffurther enlargement of the recess is desired.

The rotation of the cutting tool or band 524 is halted when a desiredsize of the recess is achieved. The push wire 514 is then released torestore the cutting head 520 to the straight shape depicted in FIG. 33.The cutting tool 500 is either retracted completely from or is retractedto a more caudal location within the posterior or anterior TASIF axialbore 22 or 152 to counterbore a more caudal counterbore recess in thesame manner as described above.

A Third Exemplary Counterbore Tool:

A further cutting tool 600 is depicted in FIGS. 35 and 36, wherein theschematically depicted drive motor 602 is coupled to the proximal end ofa drive shaft 604 within the lumen 606 of an elongated, movable,flexible outer sheath 610. A cutting head 620 is attached to and extendsdistally from the drive shaft distal end 618 to a cutting tool distalend 622.

The cutting head 620 is formed of a one or a plurality N of abradingcables 624 ₁-624 _(n) that are attached to or crimped into a lumen ofthe drive shaft distal end 618 and are of relatively short length. Theabrading cables 624 ₁-624 _(n) are formed of a woven or braided metal orfabric that are preferably coated or otherwise formed with an abrasivecompound and tend to spring outward when unrestrained.

The cutting head 620 is advanced to the site for forming the recess 154while retracted within the outer sheath lumen 606 as shown in FIG. 35.Then, the outer sheath 610 is retracted by pulling back on the handle orgrip 616 and the abrading cables 624 ₁-624 _(n) extend outward. The freeends of the abrading cables 624 ₁-624 _(n) flail against and abrade awaythe surrounding vertebral body bone when the drive shaft 612 is rotatedby drive motor 602. The drive shaft 612 can be retracted or extendedwithin the TASIF axial bore to form a recess of a desired length.

The abrading cables 624 ₁-624 _(n) are depicted as extending distallyfrom the drive shaft distal end 618, so that they tend to spread apartto flail at the surrounding bone when the drive shaft 612 is rotated bydrive motor 602. However, it will be understood that the abrading cables624 ₁-624 _(n) can be attached to the drive shaft 612 to extend at rightangles to the drive shaft 612 such that they are wound about it whenretracted within lumen 606. Then when the abrading cables 624 ₁-624 _(n)are released, they tend to extend outward laterally to the axis of thedrive shaft 612 when it is rotated.

A Fourth Exemplary Counterbore Tool:

More rigid boring or cutting elements can be employed than flexiblecables including knives, routing bits and saw teeth that are retractedwhen passed through the TASIF axial bore and then either passively oractively extended outward to bore out a recess in the axial bore wall.FIGS. 37-40 depict an exemplary embodiment of a counterbore tool 700 forforming an anchoring recess of the type depicted in FIG. 29. The cuttinghead 720 comprises a pair of cutting blades 724 ₁ and 724 ₂ that arelocated in a cross-bore 740 as shown in FIG. 40 and are retracted duringintroduction as shown in FIG. 37 and extended in use as shown in FIGS.38-40.

The schematically depicted drive motor 702 is coupled to the proximalend of a drive shaft 704 that is enclosed within the lumen 706 of anelongated flexible sheath 710 that is movable from an advanced positionof FIG. 37 to a retracted position of FIGS. 38-40. The drive shaft 704is formed with a drive shaft lumen 712 extending from the drive motor702 to the junction 718 with the cutting head 720 that extends to thedrive shaft distal end 722. The drive shaft lumen 712 encloses a twistwire 714 that extends proximally from the drive shaft connection withthe drive motor 702 through the drive motor 702 to a proximal twist wiremanipulator 716. The distal end of the twist wire 714 is forked to formpins 742 and 744 that are extended through bores 746 and 748,respectively, of cutting blades 724 ₁ and 724 ₂, respectively.

The cutting blades 724 ₁ and 724 ₂ are normally located within the bore740 as the recess forming tool 400 is inserted through the posterior oranterior TASIF axial bore 22 or 152 to a selected site, e.g., thecephalad end within the most cephalad lumbar vertebral body, in theconfiguration depicted in FIG. 37. The outer sheath 710 may or may notbe employed, but extends over the retracted cutting blades 724 ₁ and 724₂ as depicted in FIG. 37.

Then, twist wire 714 is twisted from proximal manipulator 716 and fixedat an extended position to commence counter boring the recess within thesoft spongy cancellous bone of the vertebral body. The sharp edges ofthe cutting blades 724 ₁ and 724 ₂ cut away the surrounding vertebralbone. The twist wire 714 can be twisted further so that the cuttingblades 724 ₁ and 724 ₂ extend further outward as the boring progressesIf further enlargement of the recess is desired. An automatic twistmechanism can be substituted for the proximal manipulator 716 to causeit to automatically twist the twist wire 714 as the recess is enlarged.

The rotation of the cutting head 720 is halted when a desired size ofthe recess is achieved. The twist wire 714 is then twisted in theopposite direction to retract the cutting blades 724 ₁ and 724 ₂ to theretracted position of FIG. 37. The cutting head 720 is either withdrawncompletely from or is retracted to a more caudal location within theposterior or anterior TASIF axial bore 22 or 152 to counterbore a morecaudal counterbore recess in the same manner as described above.

There are other possible ways of restraining and extending the cuttingblades 724 ₁ and 724 ₂ within and from the bore 740. In one alternativeembodiment, the cutting blades 724 ₁ and 724 ₂ can be loosely restrainedor hinged within the bore 740 such that centrifugal force causes thecutting blades 724 ₁ and 724 ₂ to extend outward as the drive shaft 704is rotated by motor 702 and the soft cancellous bone of the vertebralbody is cut away. In a further approach, the centrifugal force can beaugmented by trapped springs within the bore 740.

A Fifth Exemplary Counterbore Tool:

FIGS. 41 and 42 depict an exemplary embodiment of a counterbore tool 800for forming an anchoring recess of the type depicted in FIG. 29. Thecutting head 820 comprises an elongated spade bit or blade 824 that ispivotal from an in-line retracted configuration depicted in FIG. 41during introduction and withdrawal and an deployed extended positiondepicted in FIG. 42. The elongated blade 824 is pivotally attached tothe drive shaft distal end 818 and to the distal end of push wire 814 tomove a cutting edge 832 into contact and away from with cancellous bone.One of several possible shapes for the cutting edge 832 of the cuttingblade 824 is depicted in FIGS. 41 and 42.

The schematically depicted drive motor 802 is coupled to the proximalend of a drive shaft 804 that is enclosed within the lumen 806 of anelongated flexible sheath 810 that is movable from an advanced positionof FIG. 41 to a retracted position of FIG. 42. The outer sheath 810extends between a proximal sheath manipulator 826 and a distal sheathend 836.

The drive shaft 804 is formed with a drive shaft lumen 812 extendingfrom the drive motor 802 to the junction 818 with the cutting head 820that extends to the drive shaft distal end 822. The drive shaft lumen812 encloses a tip deflection wire 814 that extends proximally from thedrive shaft connection with the drive motor 802 through the drive motor802 to a proximal tip deflection wire manipulator 816. The distal end ofthe tip deflection wire 814 is attached to proximal extension 834 ofblade 824 via a rotatable connection.

A pin and slot hinge 830 is formed between the blade 824 and in thedrive shaft end 822. A flange having an elongated slot is formed insidethe drive shaft lumen 812, and a hole is formed through the blade 824.The proximal end of a hinge pin is trapped within the elongated slot,and the distal end of the hinge pin is trapped within the circular holeformed through the blade 824. There are many possible equivalent ways ofhinging and extending the cutting blade 824 to angle the cutting edge832 to the cancellous bone.

In use, the cutting tool 820 is introduced to the site within the TASIFaxial bore 22 or 152 where the recess is to be formed with the cuttingblade 824 in the retracted position of FIG. 41. When the tip deflectionwire 814 is pushed, the proximal end of the hinge pin slides along theslot toward its distal end, and the distal end of the hinge pin rotateswithin the circular hole, thereby pivoting the cutting blade 824 fromthe retracted position of FIG. 41 to the extended position of FIG. 42.Then, the drive motor 802 is energized to rotate the drive shaft 804 andthe extended cutting blade 824. Again, pushing force can be appliedmanually or automatically on the tip deflection wire manipulator 816 asthe cutting blade 824 is rotated and cuts away the cancellous bone tothereby incrementally extend the cutting blade from the retractedposition of FIG. 41 to the fully extended position of FIG. 42. Thecutting tool 820 can be moved distally or proximally to lengthen andshape the recess that is formed.

The rotation of the cutting head 820 is halted when a desired size andshape of the recess is achieved. The tip deflection wire 814 is pulledproximally, causing the proximal end of the hinge pin to slide along theslot to its proximal end and the distal end of the hinge pin to rotatewithin the circular hole. The cutting blade 824 then pivots from theextended position of FIG. 42 to the retracted position of FIG. 41. Therecess forming tool 800 can then be retracted. The cutting head 820 iseither withdrawn completely from or is retracted to a more caudallocation within the posterior or anterior TASIF axial bore 22 or 152 tocounterbore a more caudal counterbore recess in the same manner asdescribed above.

SUMMARY

It will be understood that features of the above described cutting headscan be substituted for one another or combined together. For example,abrading materials or abrasive coated surfaces may substituted forsharpened cutting blade edges or added to such edges or to cutting wiresurfaces.

The curved, posterior and anterior TASIF axial bores 22 and 152 that areformed in step S200 of FIG. 6 as described above start in the sacrum atthe respective posterior and anterior target points and extend upwardlyor cephalad through the vertebral body of S1 or S2 and through thecephalad vertebral bodies including L5 and L4 and the intervening discsdenoted D4 and D5 in FIG. 1. Discs D4 and D5 are usually damaged or havedegenerated between lumbar spine vertebrae and cause the painexperienced by patients requiring intervention and fusion of thevertebrae. An inspection of the vertebral bodies and discs along thesides of the posterior or anterior TASIF axial bore 22 or 152 can bemade using an elongated endoscope inserted therethrough (or through apilot hole if one is formed earlier). A discectomy or disc augmentationand/or vertebroblasty may be performed pursuant to step S300 of FIG. 6through the posterior or anterior TASIF axial bore 22 or 152 to relievethe patient's symptoms and aid in the fusion achieved by insertion of aspinal implant. In such procedures, materials or devices can be insertedthrough the curved, posterior and anterior TASIF axial bores 22 and 152to fit into excised disc space or damaged vertebral bodies.

It will be understood that various types of axial spinal implants can beinserted into the above-described curved, posterior and anterior TASIFaxial bores 22 and 152. When a counterbore recess is formed as describedabove, it receives anchor members of the axial spinal implant tomaintain it in place. Such axial spinal implants can be combined withlaterally installed disc replacements or spacers.

The preferred embodiments of the present invention for forming recesseswithin axial bores have been described above in relation specifically tocurved axial bores. However, it will be understood that the methods andapparatus for forming such recesses can advantageously be practicedwithin straight or relatively straight axial bores. Moreover, it will beunderstood that such recesses may be formed at the caudal end of theaxial bores or at one or more location intermediate the cephalad andcaudal ends of straight, curved, and diverging axial bores.

1. An apparatus configured for insertion in to a series of adjacentvertebrae located within a spine having an anterior aspect, a posterioraspect and an axial aspect from an anterior or posterior sacral targetpoint of a sacral vertebra extending in the axial aspect through theseries of adjacent vertebrae, wherein the axial aspect is curved in theposterior-anterior plane due to curvature of the spinal column, thevertebrae separated by intact or damaged spinal discs, the apparatuscomprising: a sheath extending between a sheath proximal end and asheath distal end, the sheath having a sheath lumen at least partiallyextending through a trans-sacral axial bore from the accessed sacraltarget point cephalad and axially through one or more vertebral bodiesof the series of adjacent vertebrae and any intervertebral spinal discs;and a tool sized to fit within the axial bore, the tool adapted to beinserted from the accessed sacral target point to a selected locationalong the axial bore, the tool operable from within a section of theaxial bore, the tool comprising deployment/retraction means fordeploying the tool between a retracted locked position and a deployedlocked position.
 2. The apparatus of claim 1, wherein the retractedlocked position comprises a radially retracted locked position.
 3. Theapparatus of claim 1, wherein the retracted locked position comprises anaxially retracted locked position.
 4. The apparatus of claim 1, whereinthe deployed locked position comprises a radially deployed lockedposition.
 5. The apparatus of claim 1, wherein the deployed lockedposition comprises an axially deployed locked position.
 6. The apparatusof claim 1, further comprising rotating means for rotating the tool fromthe sheath distal end.
 7. The apparatus of claim 6, the rotating meansconfigured for removal of vertebral bone or disc material.
 8. Theapparatus of claim 1, wherein the tool further comprises at least onefilament attached to the shaft distal end.
 9. The apparatus of claim 1,wherein the tool further comprises at least one wire attached to theshaft distal end.
 10. The apparatus of claim 1, wherein the tool furthercomprises at least one abrading cable attached to the shaft distal end.11. The apparatus of claim 8, wherein the at least one cable is formedof a length of woven or braided metal or fabric tending to springoutward when unrestrained.
 12. The apparatus of claim 1, wherein thetool further comprises: a cutting blade extending from the sheath distalend; a mechanism controlled from the sheath proximal end, the mechanismenabling movement of the cutting blade between an axially alignedposition and a radially pivoted position.